HLT54121 Diploma of Nursing – Advanced Health Assessment and Clinical Reasoning

Assessment 3: Adult Focused Health Assessment and SOAP Note Case Study (2026)

1. Course and Assessment

Qualification: HLT54121 Diploma of Nursing (Australian AQF 5, Enrolled Nurse preparation)

Unit alignment:

• HLTAAP003 Analyse and respond to client health information

• HLTENN043 Implement and monitor care for a person with acute health conditions

• HLTENN042 Implement and monitor care for a person with chronic health conditions

Institution type: Australian TAFE or dual-sector provider, adaptable to first-year BSN health assessment modules in Australia, the United Kingdom, the United States, and Canada

Assessment label: Assessment 3 – Individual Written Case Study and SOAP Note

Assessment type: Health assessment report and structured SOAP note based on a provided adult patient case

Weighting: 30% of overall unit grade

Length: 1,200–1,500-word written report (approximately 3–4 typed pages) plus completed SOAP template

Mode: Individual, written, submitted via LMS (Word or PDF)

Due: Week 7 (end of Study Period 1) – refer to unit schedule for exact date

Prerequisite learning: Successful completion or concurrent enrolment in Anatomy and Physiology, foundational Health Assessment skills laboratories, and at least one simulated or real clinical placement shift

2. Assessment Overview and Rationale

In contemporary nursing programs, students are expected to move beyond checklist assessments and demonstrate integrated clinical reasoning, safe health assessment, and accurate documentation through structured case-based assignments and SOAP notes. This assessment mirrors current practice in Australian TAFE Diploma of Nursing programs and North American and UK BSN and MSN advanced health assessment courses, where students apply a systematic assessment framework to complex but common adult presentations.

You will interpret a brief case scenario, gather and prioritise subjective and objective data, identify actual and potential problems, and document findings using a professional SOAP note structure aligned with current higher-education rubrics for nursing assessment tasks. The goal is to demonstrate safe, evidence-informed decision-making appropriate to the Enrolled Nurse or novice Registered Nurse scope of practice.

3. Case Scenario (Provided in LMS)

The LMS will provide one of the following adult cases, allocated by your educator:

• Case A – Mr James Walker (56 years): Known hypertension and type 2 diabetes, presents to the medical ward following an episode of chest discomfort and shortness of breath on exertion.

• Case B – Ms Lila Thapa (42 years): Recent migrant with a history of asthma, admitted through the emergency department with wheeze, increased work of breathing, and anxiety following exposure to a known trigger.

• Case C – Mrs Fatima Ali (68 years): Frail older adult with osteoarthritis and chronic heart failure, admitted from home with reduced mobility, oedema, and increased fatigue.

Each case pack includes a short narrative, vital signs chart, focused assessment findings, current medications, and relevant pathology or imaging summaries modelled on current diploma and BSN case-study materials.

4. Assessment Task Instructions (Student-Facing)

4.1 Task Summary

Write a 1,200–1,500-word health assessment report and complete a structured SOAP note for your allocated adult case. Demonstrate safe and systematic data collection, accurate interpretation of normal and abnormal findings, and beginning-level clinical reasoning suitable for an Enrolled Nurse or junior Registered Nurse.

Your report must clearly show how you:

• Use assessment data to identify priority problems

• Consider risks of deterioration

• Communicate effectively with the Registered Nurse and wider interprofessional team

• Document findings using accepted professional standards

4.2 Step-by-Step Requirements

1. Summarise the Patient Presentation (150–200 words)

• Identify the patient using initials, age, gender, and relevant background information such as reason for admission, key comorbidities, and medications.

• Provide a concise summary of the current problem and clinical context, for example medical ward, emergency department, or day procedure unit.

2. Present Focused Subjective Data (200–250 words)

• Identify key symptoms using an organised framework such as OPQRST or OLD CART where appropriate.

• Include at least five relevant review-of-systems questions.

• Address psychosocial, cultural, or communication factors that may influence assessment and care.

• Clearly distinguish between information obtained directly from the patient and information sourced from family, medical records, or ambulance documentation.

3. Present Focused Objective Data (250–300 words)

• Summarise vital signs, focused physical assessment findings, and relevant investigations grouped by body system.

• Identify which findings are within expected range and which are abnormal for this specific patient.

• Support your reasoning with at least one recent scholarly source.

• Comment briefly on trends or changes over time where data are available, such as rising respiratory rate or decreasing oxygen saturation.

4. Identify and Justify Priority Nursing Problems (250–300 words)

• Identify two actual and one potential priority nursing problem.

• Support each problem with two to three subjective and objective cues from the case.

• Explain clearly why each problem is a priority at this stage of admission, including risks of deterioration.

• Use accurate nursing terminology consistent with EN or novice RN scope of practice.

5. Outline Initial Nursing Actions and Escalation (200–250 words)

• For each priority problem, describe three to four appropriate initial nursing actions within EN or novice RN scope.

• Clearly indicate where consultation or escalation to the Registered Nurse, medical officer, or rapid response team would occur.

• Link at least one intervention to a current local or national clinical guideline relevant to the case.

• Include one example of structured communication using ISBAR to demonstrate safe handover of a key concern.

6. Complete the SOAP Note Template (Not Counted in Word Limit)

• Transcribe your assessment into the provided SOAP template in the LMS.

• Ensure consistency between your narrative report and SOAP sections.

• Use appropriate professional terminology, approved abbreviations, and logical sequencing aligned with contemporary higher-education SOAP marking rubrics.

7. Scholarly Support and Referencing

• Integrate at least three recent peer-reviewed sources (2018–2026).

• Include one current clinical guideline relevant to the case.

• Use APA 7th edition or the institutional referencing style as directed.

---

4.3 Formatting and Submission

• 1,200–1,500 words for the report excluding title page, headings, SOAP template, and reference list.

• Typed, double-spaced, 11–12-point accessible font such as Arial, Calibri, or Times New Roman.

• Use clear headings aligned with the task steps above.

• Submit a single document that includes your report, completed SOAP note, and reference list via the LMS before the deadline.

5. Marking Rubric (100 Marks Total)

The rubric aligns with common university and graduate-entry nursing SOAP note and health assessment marking patterns.

6. Academic Integrity and Support

• Work must be your own and must not be generated by unacknowledged third parties.

• Copying from commercial nursing paper sites or sharing completed assignments breaches academic integrity policies.

• You may discuss the case with peers but must submit an individual report and SOAP note written in your own words.

• Use institutional writing and learning support services for assistance with structure, academic language, or referencing.

7. Sample Answer

Mr J.W. is a 56-year-old man admitted to the medical ward following an episode of central chest discomfort and shortness of breath that occurred while climbing stairs, with symptoms partially resolving after rest and self-administered glyceryl trinitrate spray from a previous prescription. His history of poorly controlled hypertension, type 2 diabetes, and hyperlipidaemia, combined with exertional chest pain radiating to the left arm and a blood pressure of 168/94 mmHg, places him at high risk of acute coronary syndrome, so impaired cardiac tissue perfusion is an immediate nursing priority. Evidence-based guidelines emphasise early recognition of ischaemic chest pain, continuous ECG monitoring, timely administration of prescribed antiplatelet therapy, and prompt escalation if pain, haemodynamics, or ECG changes worsen, making frequent vital sign assessment and close observation essential in the first hours of admission.

---

8. Academic Integration Paragraph

Structured clinical reasoning models provide a framework for organising assessment data, recognising patterns, and prioritising nursing responses in complex adult presentations. The five rights of clinical reasoning emphasise accurate interpretation of cues, identification of patient risks, and timely intervention to prevent deterioration. Educational research indicates that explicit teaching of clinical reasoning frameworks enhances nursing students’ ability to detect and manage at-risk patients in acute settings (Levett-Jones et al., 2019). Integrating systematic reasoning processes into SOAP documentation strengthens both patient safety and professional accountability.

9.  Scholarly References

• Amsterdam E A, Wenger N K, Brindis R G et al. (2014) 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. Journal of the American College of Cardiology, 64(24), e139–e228.

• Jarvis C (2020) Physical Examination and Health Assessment. 9th edn. St. Louis: Elsevier.

• Epstein M L, Martin K, Krajewski A et al. (2019) Clinical reasoning in nursing students: A concept analysis. Nurse Education Today, 74, 1–8.

• Gulanick M, Myers J L (2021) Nursing Care Plans: Diagnoses, Interventions, and Outcomes. 10th edn. St. Louis: Elsevier.

• Levett-Jones T, Hoffman K, Dempsey J et al. (2019) The five rights of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically at-risk patients. Nurse Education Today, 79, 35–40.

• National Institute for Health and Care Excellence (2020) Acute coronary syndromes in adults. London: NICE.